Rectal bleeding and haemorrhoids

Published on 09/04/2015 by admin

Filed under Gastroenterology and Hepatology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1515 times

Chapter 20 RECTAL BLEEDING AND HAEMORRHOIDS

KEY POINTS

Rectal bleeding:

• Initial management of massive rectal bleeding always involves assessment and resuscitation.
• Colonoscopy, radiolabelled red cell scan, selective mesenteric angiography, and computed tomography angiography can be used to identify the site of bleeding. Angiographic embolisation can stop localised bleeding. In stable patients, capsule endoscopy is useful to detect vascular lesions.
• On-table gastroscopy, colonoscopy, and enteroscopy should be considered if the site of massive rectal bleeding is in doubt. Partial or total colectomy may be required if bleeding is not controlled.

Haemorrhoids:

• First-degree haemorrhoids do not prolapse, second degree prolapse on defecation but return spontaneously, third degree prolapse but require manual reduction, and fourth degree prolapse and are not reducible.
• Conservative treatment includes advice to avoid prolonged straining and fibre supplementation. Injection sclerotherapy and rubber band ligation are the two most common interventional treatment options for first- and second-degree haemorrhoids. Haemorrhoidectomy is usually reserved for third- and fourth-degree haemorrhoids.

RECTAL BLEEDING

Causes

Bleeding per rectum can originate from the stomach, duodenum, small intestine, colon or anorectum (Table 20.1). The diagnosis of colorectal neoplasia should be entertained in most cases: 1 in 20 patients over the age of 45 years of age who present with new onset rectal bleeding have colon cancer. The colour of the blood may indicate the source of the bleeding but the rate of bleeding needs to be taken into account. Haematochezia is the passage of bright red blood per rectum and usually indicates bleeding from the distal colon, rectum or anal canal. Dark red blood mixed in with bowel motions usually originates from the small intestine or proximal colon. Melaena, the passage of black tarry stools with characteristic odour, occurs with bleeding proximal to the ligament of Treitz.

TABLE 20.1 Causes of rectal bleeding

Region Causes
Anorectum
• Haemorrhoids
• Anal fissure
• Rectal prolapse/solitary rectal ulcer
• Anal fistula
• Anal varices
• Anal cancer

Colonic
• Diverticular disease
• Angiodysplasia
• Colitis (inflammatory, ischaemic, infective, pseudomembranous, radiation)
• Neoplasia/polyp
• Post-polypectomy/anastomosis bleeding

Other (stomach, small intestine)
• Upper gastrointestinal sources (peptic ulcer, erosions, Mallory-Weiss tear, oesophagitis, varices, neoplasia)
• Small intestine angiodysplasia
• Meckel’s diverticulum and ulcer

Other symptoms are useful to help localise the site of bleeding. Epigastric pain, heartburn and haematemesis or melaena are symptoms associated with bleeding from the upper gastrointestinal tract. Significant weight loss is associated with malignancy and inflammatory bowel disease. Change in bowel habit, tenesmus (feeling of incomplete evacuation) and blood mixed in with faeces are consistent with colonic pathology. Bloody diarrhoea indicates the possibility of colitis. Bright red rectal bleeding not mixed with faeces, blood on the toilet paper and anal pain or discharge are symptoms more indicative of an anorectal source. Personal and family history of colonic polyps, cancer and inflammatory bowel disease are important to elicit.

The site and cause of bleeding can be identified by appropriate investigations such as proctoscopy, sigmoidoscopy, colonoscopy and upper endoscopy. In stable patients, capsule endoscopy is useful to detect vascular lesions. Small intestine endoscopy is worth considering in difficult diagnostic cases with recurrent bleeding (e.g. double-balloon enteroscope).

Causes of massive rectal bleeding

Common causes of massive rectal bleeding include colonic diverticular disease and angiodysplasia. Diverticula in the colon are caused by increased intraluminal pressure together with segmentation of the colon resulting in herniation of mucosa through the muscle wall. Bleeding from diverticular disease is usually a large amount because it results from direct trauma to the adjacent penetrating vessels. It is uncommon for patients to present with diverticulitis and bleeding because the pathogenesis of the two is different. Diverticulitis results from micro-perforation of colonic diverticula. The inflammation is located on the outside of the colon with minimal intraluminal involvement. Ischaemic colitis is a more likely diagnosis if a patient presents with abdominal pain, fever, and rectal bleeding. Angiodysplasia are venous ectasia at the submucosal level and are more frequently found in the right side of the colon. They can be treated with electrocautery or argon plasma coagulation.

Other less common causes include colorectal cancer, colitis, Meckel’s diverticulum, small intestine angiodysplasia and upper gastrointestinal sources. Bleeding from radiation proctitis can be treated with sucralfate enemas, topical formalin or argon plasma coagulation. Bleeding associated with Meckel’s diverticulum is due to ulceration secondary to heterotopic gastric mucosa. Bleeding from an upper gastrointestinal source can be the cause of haematochezia in 10%–15% of cases.

Management

Management of rectal bleeding is shown in Figure 20.1. Initial management involves assessment and resuscitation. Any clotting abnormalities and other medical conditions should be corrected and optimised. Any evidence that the bleeding may be coming from the upper gastrointestinal tract should be looked for.

image

FIGURE 20.1 Management of rectal bleeding.

Bleeding stops spontaneously in most cases. Intervention is required for continual bleeding. Colonoscopy (after rapid cleansing in 12 hours), radiolabelled red cell scan, selective mesenteric angiography and computed tomographic angiography can be used to identify the site of bleeding. Red cell scan and angiography can localise the site of bleeding if it is faster than 0.5–1 mL/minute. Colonoscopic intervention or angiographic embolisation can be used to stop bleeding if an active site is identified. A Meckel’s scan (99Tc pertechnetate) can be useful in younger patients to exclude a bleeding Meckel’s diverticulum from ectopic gastric mucosa.

In cases where preoperative localising information is available via a red cell scan or angiographic embolisation is unsuccessful, partial colectomy can be performed. However if the patient remains haemodynamically unstable despite resuscitation and if preoperative localising studies have not been performed, total colectomy may be required as a last resort. On-table gastroscopy and colonoscopy should be considered if the site of bleeding is in doubt. Intraoperative enteroscopy may be required if there are any concerns that the site of bleeding is from the small intestine.

HAEMORRHOIDS

Haemorrhoids are vascular cushions of submucosal tissue in the right anterior, right posterior and left lateral positions. They keep the anal canal closed to prevent flatus incontinence. They become symptomatic when these cushions prolapse out secondary to degeneration of the supportive suspensory (Treitz) muscles—the sliding anal lining theory. The haemorrhoidal cushions derive a rich blood supply from the superior, middle and inferior rectal arteries with venous drainage via the corresponding veins. Prolapse leads to impediment of the venous drainage from the haemorrhoid by anal closure on the rectal tributaries. This results in engorgement of the haemorrhoid making it difficult to reduce, which predisposes to thrombosis.

Bleeding and prolapse are the most common symptoms. Haemorrhoids are classified according to degree of prolapse. First-degree haemorrhoids do not prolapse, second-degree prolapse on defecation but return spontaneously, third-degree prolapse but require manual reduction and fourth-degree prolapse and are not reducible. Other symptoms include discomfort or pain, mucus discharge and itch. Bleeding is usually bright red in colour (from arteriovenous communications) and is separate from the stools. The blood is noted either on the toilet paper or splattered on the toilet bowl. These symptoms are not specific for haemorrhoids and other investigations may be required.

The dentate line separates internal haemorrhoids from external haemorrhoids. Thrombosis of external haemorrhoids (otherwise called perianal haematomas) most commonly occurs from repeated trauma to the anal verge associated with a diarrhoeal illness. If a patient presents early, the best treatment is evacuation of the clot after infiltration with local anaesthesia. If the presentation is delayed for more than five days, then conservative management with analgesia is sufficient because most of the pain would have abated by then. Patients may be left with a residual anal skin tag.

Treatment

Fibre for the treatment of haemorrhoids

Treatment of haemorrhoids depends on the frequency and severity of symptoms. Conservative treatment includes advice to avoid prolonged straining, increased fluid intake and fibre supplementation. Fibre increases bowel frequency as well as faecal bulk. A meta-analysis of randomised trials showed a beneficial effect of fibre in the treatment of symptomatic haemorrhoids. However, fibre supplementation does not improve the degree of prolapse and can cause bloating.

Drug treatment of haemorrhoids

The prime objective of drug treatment is to control acute symptoms such as bleeding so that definitive treatment can be scheduled at a more convenient time. There are a number of drugs that are used in the treatment of symptomatic haemorrhoids (Table 20.2).

TABLE 20.2 Drug treatment of haemorrhoids

Type Action
Flavonoids Improve venous tone and lymphatic drainage, reduce capillary hyperpermeability
Ginkgo Increase venous tone and vessel wall resistance, decrease permeability, encourage venous blood return
Heparin sulfate Normalisation of hyperaemia and mucoid secretions
Calcium dobesilate Opposes breakdown of collagen, reduces blood hyperviscosity improving flow
Local application (nitrates, local anaesthetic preparations) Nitrates reduce anal spasm via nitric oxide action. Local anaesthetic/corticosteroid/antibacterial combinations reduce pain and bleeding
Herbal and other extracts Standardised blood leech extract reduces inflammation. Horse chestnut seed extract (aescin) fosters normal venous tone, improves venous flow, and is antiinflammatory. Other traditional remedies have astringent antiseptic, antiinflammatory and laxative properties

Micronised purified flavonoid fraction (MPFF) is an oral drug made up of 90% micronised diosmin and 10% flavonoids expressed as hesperidin. It improves venous tone and lymphatic drainage, and reduces capillary hyperpermeability by protecting the microcirculation from inflammatory processes. Trials have shown MPFF drugs to be effective in relieving acute symptoms (pain, inflammation, congestion, prolapse and use of analgesics and topical medications) as well as reducing the duration of bleeding.

Interventional treatment

Injection sclerotherapy and rubber band ligation are the two most common interventional treatment options for first- and second-degree haemorrhoids (Table 20.3). Injection sclerotherapy with phenol in almond oil causes fibrosis of the haemorrhoid at the submucosal level. Rubber band ligation involves ligation of haemorrhoidal tissue above the dentate line resulting in ischaemia of the banded tissue, with subsequent sloughing of the tissue in 7–10 days. A major secondary bleed can occur at this time if a large vessel is at the base of this banded tissue. The best treatment is to tamponade the bleeding site by insertion of a 50 mL balloon on an indwelling catheter and application of mild traction. Other complications include vasovagal syncope, pain and, rarely, sepsis. Rubber band ligation has been found to be more effective than sclerotherapy in a meta-analysis. Infrared coagulation and electrocautery cause tissue destruction and submucosal fibrosis.

TABLE 20.3 Interventional treatment of haemorrhoids

Type Action
Injection sclerotherapy Fibrosis at submucosal level
Rubber band ligation Strangulation of haemorrhoids above dentate line and subsequent sloughing
Infrared coagulation, cryotherapy, and electrocautery Tissue destruction and fibrosis at submucosal level
Haemorrhoidectomy Excision of haemorrhoids with preservation of sphincters and skin/mucosal bridges
Stapled haemorrhoidopexy Excision and stapling of circumferential rectal mucosal cuff above haemorrhoids to elevate prolapse and interrupt blood supply
Other treatment: HAL (haemorrhoidal artery ligation) Ligate haemorrhoidal vessels with ultrasound guidance

Haemorrhoidectomy is usually reserved for third- and fourth-degree haemorrhoids. It involves surgical excision of the haemorrhoids with protection of the internal anal sphincter and preservation of mucosal and skin bridges between the wounds. The preservation of bridges prevents anal stenosis. Residual small haemorrhoids in these areas can be removed submucosally or left for future treatment, usually by rubber band ligation. The wounds can be left opened, closed or semi-closed by leaving the external portion of the skin wound open. Pain is the most common problem after this operation. The use of metronidazole has been shown in prospective, double-blind randomised trials to reduce pain after open haemorrhoidectomy but not with the closed operation.

New ways to treat haemorrhoids have been devised. The LigaSure™ (Valleylab) instrument uses bipolar diathermy and the Harmonic Scalpel® (Johnson & Johnson) relies on high frequency ultrasonic waves to seal blood vessels. Less blood loss and postoperative pain may occur with these new techniques. Stapled haemorrhoidopexy involves resuspending the internal haemorrhoids by excising a circumferential cuff of rectal mucosa proximal to the dentate line with a circular stapler. Complications of this technique include bleeding, faecal urgency, residual skin tags, incontinence and sepsis. Haemorrhoidal artery ligation involves direct ligation of haemorrhoidal vessels localised by an endoanal Doppler ultrasound.

SUMMARY

Rectal bleeding can originate from the stomach, duodenum, small intestine, colon or anorectum. Colorectal neoplasia should be considered and excluded particularly in any patient over the age of 40 years.

The site and cause of bleeding can be identified by appropriate investigations. Common causes of massive rectal bleeding include colonic diverticular disease and angiodysplasia. Ischaemic colitis should be considered if the patient presents with abdominal pain, fever and rectal bleeding.

Initial management involves assessment and resuscitation. Bleeding stops spontaneously in most cases. Intervention is required for continual bleeding.

Haemorrhoids are vascular cushions of submucosal tissue in the right anterior, right posterior and left lateral positions. Bleeding and prolapse are the most common symptoms. Haemorrhoids are classified according to degree of prolapse. The prime object of drug treatment is to control acute symptoms such as bleeding. Drugs used include micronised purified flavonoid fraction (MPFF) and calcium dobesilate and local applications. Injection sclerotherapy and rubber band ligation are the two most common interventional treatment options. Haemorrhoidectomy is usually reserved for third- and fourth-degree haemorrhoids.

FURTHER READING

Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 4, 2005. CD004649

Brandt LJ. Bloody diarrhea in an elderly patient. Gastroenterology. 2005;128:157-163.

du Toit J, Hamilton W, Barraclough K. Risk in primary care of colorectal cancer from new onset bleeding: 10 year prospective study. Brit Med J. 2006;333:69-70.

Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005;21:1281-1298.

Hewett PJ, Maddern GJ. Haemorrhoids: evidence? ANZ J Surg. 2004;74:679-680.

Misra MC, Imlitemsu. Drug treatment of haemorrhoids. Drugs. 2005;65(11):1481-1491.

Related posts:

Alcoholic liver disease Chronic non-viral hepatitis Chronic pancreatitis Suspected iron overload or high serum ferritin Medical problems after liver transplantation The hepatitis B-positive patient